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Sliding-T Dorsal Inlay Urethroplasty

The "Sliding-T" dorsal inlay urethroplasty is a single-stage buccal-mucosal graft repair for fossa navicularis strictures, described by Hoare, Fersovich, Saavedra and Rourke. Their retrospective series reported success in 25/27 patients at mean 29.6 months.[1] It should be distinguished from separately described glans-sparing transurethral and subcoronal techniques.[1][4][7]

For the broader Asopa dorsal-inlay principle, see Asopa Dorsal Inlay OMG. For graft material, see Buccal Mucosa Graft. For the transurethral variant, see Transmeatal Ventral Inlay OMG.

The Challenge of Fossa Navicularis Strictures​

Fossa navicularis strictures are among the most technically challenging urethral strictures to reconstruct. The ideal repair must simultaneously achieve four goals:[1][2]

  1. An unobstructed urethra
  2. A slit-like meatus (cosmetically normal)
  3. Preservation of sexual function (erectile function, glans sensation)
  4. A cosmetically acceptable glans, with counseling about altered appearance and wound healing

The authors note that endoscopic treatment typically offers only temporary relief and may necessitate lifelong instrumentation.[1] Meatotomy or meatoplasty can be definitive for selected distal disease: in Meeks's two-institution series, meatotomy succeeded in 87% and meatoplasty in 75%; mean clinical follow-up across the 93-man cohort was 61 months.[8] The AUA Urethral Stricture Disease Guideline Amendment (2023) states that surgeons should offer urethroplasty to patients with recurrent meatal or fossa navicularis strictures .[3] It also notes that lichen sclerosus (LS) strictures are less likely to be reconstructed successfully with genital skin, and that success of oral mucosal grafts of 83–100% has been reported.[3]

Operative Concept​

The operation augments the distal urethra with a dorsal inlay BMG in a T-shaped reconstruction, applying the Asopa dorsal inlay principle to the fossa navicularis.[1] Distal graft placement requires suitable glanular tissue, a tension-free mucosal repair and adequate meatal caliber. The graft bed at the fossa navicularis is glanular tissue, not the tunica albuginea of the corpora cavernosa that supports a penile or bulbar dorsal inlay.

As summarized in a later technical review, the Sliding-T uses a ventral glans split and urethral spatulation, followed by a dorsal urethrotomy and lateral T-shaped incisions. After the buccal graft is secured, the urethra is tubularized and the glans wings are closed externally.[1][16] See the original operative video article. The transurethral inlay and subcoronal dorsal onlay repairs are separate operations with their own incision and closure steps.[4][7]

Outcomes (Rourke Series)​

ParameterResult
Number of patients27
Mean age47.3 yr (range 19–71)
Mean stricture length3.2 cm ± 1.2 (range 1–4)
Stricture etiologyLichen sclerosus 70.4%; iatrogenic 18.5%; idiopathic 11.1%[1]
Prior failed endoscopic treatment92.6%[1]
Prior failed urethroplasty7.4%[1]
Anatomic success (easy passage of a 16 Fr flexible cystoscope)25/27 (approximately 93%)[1]
Mean anatomic follow-up29.6 mo (range 12–60); satisfaction, erectile dysfunction and chordee assessed at approximately 6 mo
Recurrence managementBoth recurrences managed with meatotomy
90-day complications (Clavien ≥2)7.4% (2/27); surgical site infection treated with antibiotics[1]
De novo erectile dysfunction3.7% (1/27)[1]
Chordee3.7% (1/27); mild[1]
Patient satisfaction96.3% (26/27) satisfied[1]
[1]

Nineteen of 27 patients had LS. The Sliding-T cohort supports feasibility in selected LS strictures without comparing distal repairs. In a separate mixed cohort of 733 urethroplasties from the same institution (median follow-up 12.3 years), LS was independently associated with late recurrence (HR 4.46, 95% CI 2.25–9.53).[5]

Other Fossa Navicularis Techniques​

The selected nonrandomized series below differ in anatomy, etiology, success definitions and follow-up.

TechniquenStricture lengthSuccessFollow-upKey features
Sliding-T dorsal inlay BMG (Rourke)[1]273.2 cm25/2729.6 moT-shaped dorsal inlay; single-stage; 19/27 had LS
Transurethral dorsal inlay BMG (Farrell)[4]161.7 cm93.8% anatomic; 100% functional28.8 moTransurethral; glans-sparing; shorter strictures
Dorsal inlay BMG (Zumstein / Hamburg)[2]32—69%42 mo50% hypospadias-associated; mixed etiology; longer follow-up
Dorsal inlay oral mucosa (Wirtz / Belgium)[6]40meatal only82.5% (5-yr RFS 85%)85 moLongest follow-up; 5-yr RFS 96% with buccal (n = 25) versus 65% with lingual (n = 15) mucosa; nonrandomized
Dorsal BMG onlay by subcoronal approach (Favre)[7]165.5 cm100%41.5 moSubcoronal approach; longer strictures extending into penile urethra
Meatotomy (Meeks / Barbagli)[8]73short87%61 mo (overall 93-man cohort)Simplest approach; 84% satisfied or very satisfied in the questionnaire subset; higher recurrence in LS (20.5% versus 7.5%) across all distal repairs
Extended meatotomy / first-stage Johanson (Morey)[9]16complex87% (14/16)52 mo (overall 40-man cohort)Salvage for complex or reoperative distal strictures
Ventral transverse island flap (Jordan)[10]5variable5/5 excellent cosmetic and functional results; patency endpoint not definedmedian 17 moClassic flap technique; requires glans splitting; small series
Tailored glanular reconstruction (Armenakas / McAninch)[11]19variable18/19 favorable functional/cosmetic result; mixed repairsmean 42.7 mo16 island flaps, 2 primary anastomoses, 1 buccal graft; glans cap or wings
Excision + circumferential BMG (Ehlers / Figler)[12]—severe——Glans-sparing transurethral excision; for severe / obliterative strictures
Distal one-stage hybrid (Hofer)[13]27 of 34mean 0.68 cm5/27 subgroup recurrences reported; subgroup counts conflict with 6/34 overall42.5 mo in abstract; 26.4 mo in Results (both overall)Hybrid used no graft or flap; 82.4% overall success cannot be assigned to this subgroup

Potential Role​

The Sliding-T offers one-stage oral mucosa reconstruction for selected recurrent fossa navicularis strictures, including LS strictures in which genital skin is avoided. In the initial cohort, 26/27 patients were satisfied, two developed infections requiring antibiotics, one reported new erectile dysfunction and one mild chordee.[1]

Limitations and Considerations​

  • Single-center experience. Only one group (Rourke, University of Alberta) has described the technique, in 27 patients, and independent validation is lacking.[1] The reported etiologies were LS (19), iatrogenic (5), or idiopathic (3); no separate post-hypospadias outcome was reported, so applicability after failed hypospadias repair remains uncertain.[1]
  • Stricture length. Mean length was 3.2 cm (range 1–4 cm). In Morey's separate flap/graft onlay series, 10/11 isolated fossa strictures (1.5–2.5 cm) and 7/13 pendulous strictures extending into the fossa (4–16 cm) were successfully reconstructed.[9] For longer distal strictures, a subcoronal dorsal onlay (Favre: 16 patients, median length 5.5 cm, all stricture free at 41.5 months) or staged urethroplasty has been used.[7][13]
  • Recurrence at the meatus. Both recurrences in the Rourke series were managed with meatotomy.[1]
  • Staged repair. Staged urethroplasty may be needed for complex LS-related strictures with extensive glanular involvement, when local tissue loss or scarring prevents a sound one-stage repair. A one-stage Sliding-T requires a dorsal urethral plate and glans tissue of sufficient quality to support graft take.
  • LS recurrence risk. LS is a chronic, progressive disease, and follow-up beyond 5 years is needed to assess durability.[5]

Patient Selection​

The reported experience is in the following selected patients:[1][3]

  • Prior endoscopic treatment. Among 27 patients treated for fossa navicularis strictures, 25 (92.6%) had failed prior endoscopic treatment.[1]
  • Stricture length 1–4 cm was reported for the cohort treated for fossa navicularis strictures.[1]
  • Lichen sclerosus etiology (where genital skin should be avoided)
  • Patients who choose single-stage repair after discussion of cosmetic and functional trade-offs
  • Adequate dorsal urethral plate quality to support graft take (if the plate is severely diseased or absent, staged repair may be preferable)

Postoperative Management​

After urethroplasty an indwelling catheter is commonly left for two to three weeks. The EAU 2026 guideline states that urinary extravasation should be assessed before catheter removal; with significant persistent extravasation the catheter is kept or reinserted and the study repeated after one week, whereas low-grade ("wisp-like") extravasation does not appear to affect long-term restricture rate.[14]

Symptoms, flow and residual urine are monitored, with anatomical reassessment chosen according to recurrence risk. LS needs ongoing assessment, and external genital LS may need topical therapy. Cystoscopy is selected according to the follow-up protocol and clinical findings.[3][15]

Videos​

Sliding-T Dorsal Inlay for Fossa Navicularis Strictures
Fersovich, Saavedra and Rourke, AUA 2020

References​

  1. Hoare D, Fersovich JH, Saavedra A, Rourke KF. Single-stage reconstruction of fossa navicularis strictures using a "sliding-T" dorsal inlay urethroplasty with buccal mucosal graft. Urology. 2021;152:201-202. doi:10.1016/j.urology.2020.12.031.

  2. Zumstein V, Dahlem R, Maurer V, et al. Single-stage buccal mucosal graft urethroplasty for meatal stenoses and fossa navicularis strictures: a monocentric outcome analysis and literature review on alternative treatment options. World J Urol. 2020;38(10):2609-2620. doi:10.1007/s00345-019-03035-8.

  3. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

  4. Farrell MR, Campbell JG, Zhang L, Nowicki S, Vanni AJ. Transurethral reconstruction of fossa navicularis strictures with dorsal inlay buccal mucosa graft urethroplasty. World J Urol. 2022;40(6):1523-1528. doi:10.1007/s00345-022-03994-5.

  5. Calvo CI, Fender K, Hoy N, Rourke K. Affirming long-term outcomes after contemporary urethroplasty: the adverse impact of increasing stricture length, lichen sclerosus, radiation, and infectious strictures. J Urol. 2024;211(3):455-464. doi:10.1097/JU.0000000000003826.

  6. Wirtz M, Claeys W, Francois P, et al. Treatment of meatal strictures by dorsal inlay oral mucosa graft urethroplasty: a single-center experience. J Clin Med. 2021;10(19):4312. doi:10.3390/jcm10194312.

  7. Favre GA, Villa SG, Scherñuk J, Tobia IP, Giudice CR. Glans preservation in surgical treatment of distal urethral strictures with dorsal buccal mucosa graft onlay by subcoronal approach. Urology. 2021;152:148-152. doi:10.1016/j.urology.2020.12.014.

  8. Meeks JJ, Barbagli G, Mehdiratta N, Granieri MA, Gonzalez CM. Distal urethroplasty for isolated fossa navicularis and meatal strictures. BJU Int. 2012;109(4):616-9. doi:10.1111/j.1464-410X.2011.10248.x.

  9. Morey AF, Lin HC, DeRosa CA, Griffith BC. Fossa navicularis reconstruction: impact of stricture length on outcomes and assessment of extended meatotomy (first stage Johanson) maneuver. J Urol. 2007;177(1):184-7; discussion 187. doi:10.1016/j.juro.2006.08.062.

  10. Jordan GH. Reconstruction of the fossa navicularis. J Urol. 1987;138(1):102-4. doi:10.1016/s0022-5347(17)43006-0.

  11. Armenakas NA, Morey AF, McAninch JW. Reconstruction of resistant strictures of the fossa navicularis and meatus. J Urol. 1998;160(2):359-63. doi:10.1016/s0022-5347(01)62895-7

  12. Ehlers M, Figler BD. Excision and circumferential buccal graft for severe meatus and fossa navicularis strictures. Urology. 2020;146:304. doi:10.1016/j.urology.2020.09.008.

  13. Hofer MD, Cooley LF, Elmasri A, Martins FE. Revisiting one-stage urethroplasties for distal urethral strictures. J Clin Med. 2021;10(24):5905. doi:10.3390/jcm10245905.

14. EAU Guidelines on Urethral Strictures, 2026: perioperative care. https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery. Accessed September 12, 2026.

15. EAU Guidelines on Urethral Strictures, 2026: follow-up. https://uroweb.org/guidelines/urethral-strictures/chapter/followup. Accessed September 12, 2026.

16. Cedars B, Nikolavsky D. "Transurethral ventral buccal mucosal inlay grafting: a narrative review." Transl Androl Urol. 2025;14(8):2391-2397. doi:10.21037/tau-24-615